The best and most cost-effective treatment for end-stage renal disease patients is living donor (LD) renal transplantation. It has survival benefit compared to deceased donor (DD) kidney transplant (DDKT) and long-term dialysis and provides a better quality of life. Efficient and effective kidney allocation methods are increasingly necessary to address the problem of organ scarcity. The use of kidney paired donation transplant has increased access to LD kidney transplantation (LDKT) with outstanding results. ABO-incompatible kidney transplantation (KT) and desensitization protocol can expand the donor pool, but as integral to any aggressive immunosuppression protocol, they are associated with increased risk of infection and malignancy. Given the widespread organ shortage, DDKT from donors with sepsis, donors who died from snakebite or acute kidney injury, controlled donation after cardiac death, older donors, can be considered for KT with an acceptable outcome. The acceptable outcome can be achieved with dual KT using kidneys from expanded criteria donors in older population. Dual KT from pediatric donors to adult recipients or from adult marginal DDs is a promising way to expand the donor pool. Carefully selected donor with HIV, HCV, and HBV positivity is not a contraindication for living kidney donation. Careful and meticulous selection of patient and donor is essential for successful outcome. Affordable or free transplantation is other way to increase transplantation rate in developing country. The community support can make transplantation available free to the poor patients under community-government partnership. Various steps should be taken to promote LDKT and DDKT program.

Worldwide organ shortage is one of the most common hurdles while treating patients with end-stage liver disease, especially in countries where there is lack of interest in organ donation. Apart from this, cost of this remedy is one reason, which makes this treatment distant dream for many. In such a situation, to lose even a single donor becomes too costly, cost of which is life of some other patients. Extended criteria for liver donation are already in use, though in some situations clinicians feel like trapped between providing best care and managing organ demands. One of such tricky situations is incidentally found malignancy in donor. Recently, we came across such situation during the harvest of liver from a cadaver donor, which made us go through the literature and find the answer. Here, in this review, we share that experience and try to throw light on this enigmatic issue with special focus on incidentally found malignancies in cadaver donor.

Background: Patients with end-stage liver disease frequently acquired complex disorders in hemostasis secondary to liver dysfunction. Objectives: This study aims to determine the incidence of vascular complications associated with central venous catheterization (CVC) in patients with coagulopathy and liver disease. Methods and Subjects: This multicentric, retrospective, cross-sectional study was performed on 993 patients undergoing liver transplantation who required central venous access (CVA) for their clinical management between October 2006 and October 2016. The age, sex, most recent platelet count, prothrombin time, international normalized ratio (INR), activated partial thromboplastin time, site of central venous catheter placement, and bleeding complications were retrieved from their medical records. Results: In these 993 cases, the mean age was 57.46 (standard deviation = 7.46) years, and 635 (63.9%) were male. Selected sites were the internal jugular (n = 889; 89.5%), subclavian (n = 93; 9.4%), and femoral (n = 11; 1.1%) veins. First attempt was successful in 925 cases (93.2%), in which 1 case had major bleeding, and 84 cases had minor bleeding. About 83% of the patients with liver failure take CVC procedure without any complications. None of the vascular complications occurred in 53% of the patients with low platelets and INR >1.5. Conclusion: We demonstrated major vascular complications following CVC in patients with liver disease and coagulopathy has low incidence in this audit. CVA procedures can be done safely in patients with disorders of hemostasis by skilled physicians who frequently perform these procedures.

Objective: To assess knowledge, attitude, and practices regarding organ/tissue donation. Materials and Methods: A cross-sectional descriptive study was conducted among ambulatory, consenting adult (>18 years) visitors of a mid-level government hospital using a predesigned, pretested, semistructured interview schedule. Data were analyzed by calculating proportion, Chi-square test, and odds ratio (OR). Results: Of 450 respondents, 271 (60.2%) were aged more than 31 years, 264 (58.7%) were male, 345 (76.7%) were married, 374 (83.1%) were Hindu, 304 (67.6%) had studied up to 10th class, 278 (61.8%) were working, 217 (48.2%) had 0–2 previous visit to this hospital, and 142 (31.6%) reported history of hospitalization. Majority (337, 74.9%) of the respondents had heard the term organ donation (OD). On probing further, nearly 87.3% and 82.4% of respondents had ever heard of eye and kidney donation, respectively. Encouragingly, more than half of respondents, i.e., 261 (58.0%), showed willingness for OD. Statistically (P < 0.001) higher odds for OD willingness was found among participants who were aware of the term OD (unadjusted OR [UOR] = 2.8, 95% confidence interval [CI]: 1.82–4.39), eye donation (UOR = 3.2, 95% CI: 1.78–5.76), and kidney donation (UOR = 4.0, 9.5% CI: 2.40–6.84). Similarly, higher willingness was found among single/separated participant and with higher level of education (P < 0.05). About one-fourth (120, 26.7%) of respondents had donated blood in the past, but this practice had no statistical bearing on the willingness for OD (P = 0.61). Nearly half of the respondents, i.e., 239 (53.1%), were aware that organs could be removed from both living and dead person; 373 (82.9%) of respondents were aware that organs cannot be removed from the body without authorized permission (UOR = 2.7, 95% CI: 1.57–4.88 and adjusted OR [AOR] = 2.6, 95% CI: 1.27–5.66). However, only 119 (26.4%) respondents consented to sign a pledge card for OD. Higher odds (AOR = 12.8, 95% CI: 5.02–32.75) for OD willingness was found among those who consented to sign a pledge card. A high of 364 (80.9%) respondents had no misconception that a person will be born with missing organ following donation of organ/tissue in this life. Conclusion: A high awareness but low level of positive attitude and practices was noticed among sampled metropolitan respondents toward organ/tissue donation.

A study on knowledge and attitude about organ donation among medical students in Kerala

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GS Adithyan, M Mariappan, KB NayanaDOI:10.4103/ijot.ijot_49_17

Background: The knowledge and attitude of medical students regarding organ donation is quintessential for the success of the organ donation program in a country. Objective: This study aimed to assess the knowledge and attitude of medical students regarding organ donation at Government Medical College, Trivandrum, Kerala, India. Methodology: Data of this cross-sectional study were collected by self-administered questionnaire from 194 final-year MBBS students during 2016, who were selected by convenient sampling. The questionnaire had three sections to gather information of sociodemographic details of the students, knowledge on organ donation, and the attitude toward organ donation. Results: The findings showed that a majority of the students had adequate knowledge regarding organ donation, but it is not translated into their willingness for donation – both cadaveric and live. Conclusion: The study reiterates the need for educational interventions for medical students which cut across various disciplines to make them understand the nuances of the issue in a holistic way.

Background and Aim: Post-transplant liver biopsies form a critical part of management of complications arising post-transplant. The objective of this study was to analyze the Indian experience in pathologic diagnosis of liver biopsies after orthotopic liver transplantation (OLT) with special emphasis on cases presenting with intrahepatic cholestasis (IHC). Type, incidence, and timing of major complications were analyzed. All cases with IHC were retrospectively analyzed with clinical inputs to look for cryptic clues in subclassifying such cases. Materials and Methods: Forty-five post-transplant liver biopsies from 39 OLT patients were retrospectively analyzed from May 2015 to May 2016. All biopsies were stained with hematoxylin and eosin and Masson's Trichrome, and other stains were performed as required. Results: The number of liver biopsies performed for each patient ranged from 1 to 3. The timing of these biopsies varied from 5 days to >4 years post-transplant. Of the 39 patients who underwent post-transplant liver biopsies, most common etiology of a liver transplant was hepatitis C virus (HCV)-related chronic liver disease in 66.6% cases. The common complications post-transplant were acute cellular rejection (ACR) (33.3%), biliary stricture (13.3%), HCV recurrence (11.1%), plasma cell hepatitis (4.4%), chronic hepatitis (4.4%), IHC (22.2%), and others. On analysis of post transplant biopsy cases with IHC, we found that patients with high baseline HCV RNA levels had recurrences presenting only with prominent IHC without fibrosis and ballooning of hepatocytes. These changes might represent early stages of fibrosing cholestatic hepatitis (FCH). Conclusions: This study evaluated the types, incidence, and timing of major complications occurring after OLT. ACR remains major complication following transplant. The presence of IHC on biopsy, especially in HCV-positive patients, should prompt anti-HCV therapy even if other features of FCH were not found.

Introduction: Infections are an important cause of morbidity and mortality in renal transplant recipients. This retrospective study was done to study the infection profile in renal transplant recipients. Materials and Methods: Seventy-three patients who developed infections out of 144 renal transplant recipients at a tertiary care center in southern India between January 2010 and June 2014 were studied. Infections were analyzed in terms of incidence, time of onset after transplant, clinical presentation, diagnosis, graft dysfunction, and patient and graft survival. Results: A total of 145 infection episodes were documented in the 73 patients studied. Majority (79.5%) were males and females constituted 20.5%. Predominant age group involved was 21–30 years (38.4%). Most common donor was mother (30.1%). Induction therapy was given in 21 (28.8%) patients. Mean duration of follow-up was 21.3 months. Most common infections were those of urinary tract (34.5%), followed by viral (31.2%), sepsis (15.2%), mycobacterial (9.7%), and fungal (6.2%). Parasitic infections (giardiasis and Strongyloides hyperinfection syndrome) occurred in 2 (1.4%) patients. Cytomegalovirus accounted for 14.5% and BK virus for 5.5% of total infections. Majority (77.1%) of the infection episodes occurred in the first 6 months of transplantation. There were 11 (7.6%) episodes of graft dysfunction and three patients had graft failure. A total of nine deaths were recorded due to these infections. Conclusion: Urinary tract is the most common source of infection in renal transplant recipients, followed by viral infections. Understanding the chronologic pattern of these infectious episodes facilitates early diagnosis and management of patients.

Graft-versus-host disease (GVHD) after liver transplantation, although rare, is well documented in liver transplant recipients. In this syndrome, donor T lymphocytes transferred with the graft are activated by alloantigens expressed by host antigen-presenting cells and initiate an immune response against recipient tissues, especially skin, gastrointestinal tract, and hemopoietic tissue. A descriptive study of clinical case and the management includes investigations, diagnosis, and treatment of GVHD. Diagnosis of the GVHD was based on combination of clinical features and histological features on skin biopsy. Possible differential diagnosis was ruled out on the basis of laboratory investigations. Empirical treatment with continuous immunosuppressant and antibiotics were continued. There was a transient response to the treatment with resurgence of the features culminating in multiple organ dysfunction leading to death. This first case of this rare complication in the experience of our institute of nearly one hundred and twenty liver transplantation amounts to the incidence of approximately 0.8%. This is in alignment with the worldwide incidence. The rarity of this complication coupled with fair incidence of infective complications of liver transplantation mimicking it clinically makes the diagnosis of GVHD more difficult until sought after proactively. Moreover, the balance between the immunosuppression and superadded infection thereof with ill-defined and ill-studied treatment options makes the treatment of the complication more difficult thus justifying its high mortality across the world. Although GVHD is a rare complication of LT and the mortality rate remains very high, clinical features represent an important tool for early diagnosis. The prognosis remains poor, and further research is needed to clarify the pathogenesis of GVHD and to provide new therapy.

Anesthetic and surgical management of small children is challenging because of technical difficulties and repeated re-explorations for vascular or biliary complications. Preoperative optimization and meticulous intraoperative and postoperative management can achieve the survival rates comparable to older children. In our institution, we have successfully managed living donor liver transplant in four small children ≤8 kg, and with these case reports, we have tried to present anesthetic concerns and management of these cases along with surgical and postoperative details.

The incidence of unusual fungal infections in renal allografts has been rising in the last few years. We report an unusual case of eumycotic mycetomas at multiple sites caused by a fungus Pyrenochaeta romeroi, in a 43-year-old male, farmer by occupation and renal allograft recipient. The patient had undergone a live, related donor transplant 9 months earlier, with wife as donor, and was on tacrolimus, mycophenolate mofetil and steroids. This is the only case of P. romeroi causing nodular eumycetomas at multiple sites in a renal allograft recipient. All case reports have reported single lesion and multiple lesions are uncommon.

A 44-year-old African male with chronic kidney disease Stage V due to hypertension underwent a live related renal transplant in 2005. He was on triple immunosuppression postoperatively. Subsequently, he developed metastatic Kaposi sarcoma requiring reduction in immunosuppression and switching over to rapamycin. He was found to be retrovirus positive on a follow-up visit. His graft function progressively deteriorated requiring dialysis while continuing on highly active antiretroviral therapy. He had multiple infective episodes including acute bacterial endocarditis. He received a second renal transplant from a live-related donor in 2017. Despite repeated dosage adjustments, tacrolimus levels were persistently elevated due to drug-drug interaction with diltiazem and anti-retroviral drugs, despite good allograft function.

Herpes simplex virus is a relatively less reported cause of hepatitis post transplant. Patient presented post transplant with fever, jaundice and rash. He was evaluated for causes of hepatitis. He was found to be HSV positive and was treated with Acyclovir. He developed fulminant hepatic failure. Hepatitis is an uncommon manifestation of HSV and should be considered in all post transplant patients with jaundice.

Pulmonary hypertension is a strong predictor of morbidity and mortality in patients with end stage renal disease and may be considered by many as a relative contra-indication for transplant. In this case report we describe complete resolution of pulmonary hypertension after renal transplantation.

Tuberculosis is one of the most common opportunistic infections noted after renal transplantation. It can present in unusual ways making it a diagnostic challenge. Gastrointestinal tuberculosis after renal transplantation is rarely reported. We present 2 rare cases of gastrointestinal tuberculosis that was diagnosed promptly and treated.

Dynamic renal scintigraphy scores above other methods for evaluating grafts as it can demonstrate perfusion, function, and drainage pattern. A difficult scenario in evaluating delayed graft function is excluding rejection. Perfusion indices help in the diagnosis of delayed graft function and ruling out rejection. We report a case of renal transplant recipient presenting with delayed graft function. Renal scintigraphy was performed 2-day posttransplantation. Time-activity curves were obtained for 1st min images to evaluate the perfusion of graft and iliac artery. Normal perfusion index is considered as below 150. The results were suggestive of maintained perfusion, more in favor of acute tubular necrosis. Hilson's perfusion index with appropriate modifications interpretation can rule out rejection.